Evaluation article: Learning from mistakes and incidents

Published: Wednesday, 30 March 2016

One of the reasons why providers fail CQC inspections is that they do not learn from mistakes and incidents. This article looks at how to improve after mistakes.

Summary

  • All accidents, reports of diseases, dangerous occurrences and/or near-misses should be fully investigated and reviewed.
  • All staff should be encouraged to report any accidents or untoward incidents, including 'near-misses'. All accidents and incidents should be recorded and the causes investigated.
  • Accident records should be reviewed regularly by managers to look for trends and patterns in addition to any individual investigation of the circumstances surrounding each incident.
  • Providers should use mistakes and errors to improve the quality of services.
  • Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 places a duty on service providers to report various types of incidents to the Care Quality Commission (CQC).

CQC's The State of Health Care and Adult Social Care in England 2014/15 report singled out incident investigation as lacking in care
organisations.

In all organisations, things sometimes go wrong and mistakes and errors occur. Even the best-run organisations, with robust approaches to risk management and safety and with well-trained staff working to well-thought-out policies and procedures, are not immune.

Organisations and individuals can have different attitudes towards mistakes, errors and complaints. Some see problems as a learning opportunity. They will:

  • find out what caused the problem
  • ensure that the lessons have been learned
  • change their policies and procedures to prevent the issue reoccurring
  • apologise to those affected and
  • keep them informed of changes and progress.

Other organisations and individuals may see the same circumstances as a threat and seek to play the issue down. Their investigation may only scratch the surface and address the symptoms of the problem rather than the cause. There may be no effort to find the cause because the organisation is not committed to change and fears publicity.

In organisations with an open culture, staff are encouraged to question practice and to report problems and issues, including 'near-misses' where things might have gone wrong but by luck did not. Service users are encouraged to complain if they are not getting the service they are entitled to. Incident reports and alerts are actively investigated and managed and issues are addressed.

In organisations with a closed culture, staff are encouraged to keep quiet about problems, or are expected to make do. They may feel uncomfortable about raising problems, especially if they are not sure that anything will change as a result.

Modern models of risk management are clear in seeing an organisation's attitude towards mistakes and errors as a key driver of service improvement and quality, and it is this link that the CQC strives to encourage through its inspection framework and fundamental standards.

KLOEs and rating characteristics

For both residential and community adult social care services, CQC's key lines of enquiry (KLOEs), set out in the provider handbooks, prompt inspectors to ask whether information from investigations and compliments is used to drive quality across the service.

Suggested sources of evidence and further question prompts are also set out in CQC's guidance on the KLOEs.

The rating characteristics in the provider handbooks state that in a service rated as 'good':

  • the management identifies risks to the service and manages them well
  • staff understand how to minimise risks and there is a good track record on safety and risk management
  • if action plans are required, they are monitored to make sure they are delivered
  • the service consistently focuses on how it can improve its safety record.

Incident reporting

All staff should be encouraged to report any accidents or untoward incidents, including 'near-misses'. All accidents and incidents should be recorded and the causes investigated.

Good-quality accident and incident records are valuable as managers can use them as an aid to risk assessment, helping to analyse the root causes and put in place preventative actions.

Organisations with 10 or more employees must have an accident book. Certain accidents also need to be reported to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

Accident records should be reviewed regularly by managers looking for trends and patterns in addition to any individual investigation of the circumstances surrounding each incident.

Adverse incidents involving medical devices should be reported to the Medicines and Healthcare Products Regulatory Agency.

According to the KLOE provided as guidance for CQC inspectors, managers and staff should be honest and transparent when mistakes or errors occur. All mistakes and errors should be recorded and analysed, even if they do not cause an accident, or if they just cause a 'near-miss' type of incident.

Reporting to the Care Quality Commission

Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 places a duty on service providers to report various types of incident to the CQC. Incidents to be reported include:

  • injuries
  • applications to deprive someone of their liberty
  • events that may prevent the registered person from running the service as well as they should
  • allegations of abuse
  • any police investigation.

Serious accidents or incidents where the CQC might have a concern will be investigated. All reports – or 'notifications' as they are described in the regulations – will be recorded by inspectors and used as part of their 'intelligent monitoring' process.

Accident investigation

All accidents, reports of diseases, dangerous occurrences and/or near-misses, where practicable, should be fully investigated and reviewed. There should be an attempt to get to the bottom of any incident by using 'root cause analysis' techniques.

Investigations are important so that the organisation can learn from any incident and take action to prevent things going wrong again. The prevention of accidents and incidents is important to keep people safe and can bring substantial savings to the organisation.

Complaints

Listening to service users, and to their families and representatives, is such an important element of modern adult social care that inspectors are prompted to consider evidence from complaints in all of the key questions.

Further information

Toolkit

Use the following item in the toolkit to put the ideas in the article into practice:

About the author

Martin Hodgson MSc, PGCEA is a community psychiatric nurse by background, and has had a long career working as a senior manager in various health agencies, including mental health, primary and community care.

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